Measuring maternal improvement through multi-stakeholder engagement: Documenting developments in the dynamic programmatic context of the global COVID-19 pandemic through outcome harvesting

Background To bolster country efforts towards meeting the targets and strategies laid out in WHO’s report “Strategies toward ending preventable maternal mortality” (EPMM), a series of seven consultations, known as National Dialogues, were conducted to better understand national priority areas for the improvement of maternal health and to support the adoption and use of EPMM indicators at the national level. The last Dialogue was conducted in March 2020, as the COVID-19 pandemic was beginning to have global impacts. We aimed to explore the circumstantial challenges and opportunities that countries have encountered in meeting the specific stakeholder commitments made in each country by National Dialogue participants during the COVID-19 pandemic. Methods We based our study methodology on outcome harvesting, a qualitative approach that examines how incremental change contributes towards achieving a specified outcome. It collects evidence on what has changed and then works backwards to determine whether and how a programme or intervention led to the observed changes. We collected data from 20 participants in five countries (Bangladesh, India, Mexico, Nigeria, and Pakistan) through key informant interviews and focus group discussions. We analysed the data through inductive coding focused on emergent themes. Results The onset of the global COVID pandemic overturned plans and upended health systems, bringing new opportunities in some countries and halting progress towards the agenda outlined in the National Dialogue elsewhere. Participants identified adaptations that facilitated continued progress, such as shifting the locus of advocacy and activity from national to sub-national focal areas, catalytic changes in response to the crisis (including the development and improvement of digital communication and data technology), and increased awareness of the importance of identified priorities (including a human rights approach to maternal health). Conclusions Our data suggest that the priorities for maternal health system performance to drive improvement toward ending preventable maternal deaths and the advocacy commitments designed to increase the relevance of upstream policy and health system-level determinants of maternal health and survival have retained their urgency during the COVID-19 pandemic.

tries in sub-Saharan Africa and 52% in Central Asia [2]. Achieving SDG 3 will require continued global investment and prioritisation of maternal health research, programmes, and policy. A global systematic analysis found that, while haemorrhage was the leading cause of maternal death globally between 2003 and 2000, indirect causes accounted for more than a quarter of maternal deaths [3]. To accelerate progress in reducing preventable maternal deaths, countries must push past strategies that primarily focus on the major direct causes of maternal mortality and target the upstream determinants that may be contributing to plateaus in progress.
In 2015, the WHO released the "Strategies toward ending preventable maternal mortality" (EPMM Strategies) report, outlining global targets and strategies for reducing maternal mortality in the 2015-2030 SDGs era [4], focused on human rights and system performance to eliminate disparities in access, quality, and outcomes of maternal care both within and between countries. To reach these ambitious targets, the strategies highlight 11 EPMM key themes grounded in fundamental human rights principles of equity, non-discrimination, transparency, participation, and accountability. They represent the full, broad spectrum of determinants of maternal health and survival, including social/structural, political, economic, and health system-level determinants. A comprehensive monitoring framework for each theme was developed to track national and global progress in improving maternal health [5,6]. The National Dialogues aimed to identify local priorities and support efforts to improve the availability and use of robust monitoring data for advocacy so as to advance maternal health and enhance policy, programmatic and resource-related decision-making. As the National Dialogues were being completed, country participants agreed on specific actions and made commitments based on the identified priority issues.
During the last National Dialogue in Nigeria in March 2020, COVID-19 began impacting countries worldwide. Given the complexity of advancing the maternal health measurement agenda during a global pandemic, we believe that there may have been important similarities in both the challenges faced and the lessons learned across countries. While we did not expect any country to have fully achieved all priorities and commitments set during the National Dialogues, as progress towards them was greatly impacted by the global pandemic, we believe that a cross-country synthesis of how the COVID-19 pandemic either hampered or accelerated achievements may help with identifying lessons learned regarding the impact of global and national crises that compete for attention and resources on the progress of previously adopted agendas With this study, we aimed to examine country-level developments, describe country experiences, and identify the unique and common challenges countries have faced in meeting the National Dialogues' objectives and the specific stakeholder commitments made and advocacy targets identified in each country by National Dialogue participants during the COVID-19 pandemic. As the pandemic must have affected the visibility or focus on maternal health and/or measurement plans, we sought to explore the ways and directionality in which it had done so.

METHODS
We based our study methodology on outcome harvesting, a qualitative approach that examines how incremental change contributes towards achieving a specified outcome [7]. At a basic level, it collects evidence on what has changed and then works backward to determine whether and how a programme or intervention led to the observed changes. While traditional monitoring and evaluation approaches compare expected vs achieved outcomes, outcome harvesting is better suited for dynamic programmatic contexts (where objectives and pathways to progress are unpredictable and not clearly or easily defined) and for complex programmes (where incremental change is important to capture). For example, a traditional indicator may measure the number of policies changed in a country; however, tracking this indicator quantitatively does not say anything about the multiple successes that had to be achieved along the way, which may be key in cases where substantial movement was made towards changing a policy, but the change had not yet occurred [8]. The overarching goal of outcome harvesting is not to seek sole attribution for the outcome, but to understand how an actor contributed it. Outcome harvesting seeks to understand how actors realise these changes through inspiration, support, facilitation, persuasion, or pressure [9]. Outcomes are broadly defined as any relevant change in behaviour, relationships, actions, activities, policies, or practices.

Study participants
Data sources related to the developments identified in Step 1 were key informant interviews (KIIs) and focus group discussions (FGDs). A total of 16 key KIIs and two FGDs were conducted including four participants each ( Table 1).

Data collection
Our methodology reflected the sequence and substance of the steps of outcome harvesting, condensed to six steps for feasibility reasons. We prepared a semi-structured interview guide that outlined each step. Interviews were conducted by a trained facilitator who had previously been involved at the international level in planning the National Dialogues and was thus known by most of the participants.

Step 1: Designed the outcomes for harvest
The outcome harvest focused on understanding how the National Dialogues contributed to country-level developments toward meeting the specific objectives set by participating stakeholders and how the COVID-19 pandemic affected the priorities identified in each country or influenced the developments that took place toward addressing them. Developments were defined as any positive change in behaviour, relationships, actions, activities, policies, or practices relevant to the National Dialogue objectives or ensuing commitments in each country. We further intended to understand the development's overall significance while uncovering other dimensions that led to change in the priority area, including the policy context and contributions of other actors or events and their intersection with the COVID-19 context.

Step 2: Gather data and draft outcome descriptions
The research team collected information about developments and how change agents (the actors/organisations that influence a development) contributed to achieving it.
Each FGD followed the process specified below: − First, the facilitator reviewed the dialogue objectives, priorities, action items, and commitments for each country that were agreed upon in the National Dialogue. − The facilitator discussed developments already identified in relation to those items and asked the participants to provide additional detail including the development's significance and how specific actors contributed to the change (such as through facilitating, supporting, advocacy, etc.). Contributions could be direct or indirect, partial, or whole, intended or not. − The facilitator asked for additional details related to any contributions, such as when they occurred and whether any other actors were involved. − The facilitator asked participants whether any other outside actors contributed and how, whether  or any other external events may have facilitated the change.

Step 3: Formulate outcome descriptions
The research team synthesised information from the KIIs and FGDs and developed draft outcome descriptions, which focused on who changed what, when, where, and how.

Step 4: Substantiate
The study team looked for convergence between one or more independent responses, corroborating developments to identify themes and collected supporting documentation to enhance the validity and credibility of the findings. The purpose of this step was to triangulate information.

Step 5: Analyse and interpret
The study team organised the descriptions of developments in a meaningful way to understand if and how the onset of the COVID-19 pandemic, combined with other factors, produced or impeded broader change in policy or practice domains. Additionally, results were examined across all countries to identify broad lessons learned in maternal health efforts during the COVID-19 pandemic that might provide generalisable insights applicable across countries regarding the process of improving maternal health measurement globally.

Step 6: Support use of findings
The study team fed back the case study results to the National Dialogue planning committees in the participating countries to provide them with information pertinent to decision-making, ongoing activities, or future recommendations.

Data management and analysis
We conducted all FGDs and KIIs remotely via Zoom and recorded. We transcribed the recordings and quality checked the transcripts for accuracy. We analysed all data relating to study aims using an inductive content analysis approach, coding data according to meaning and identifying emergent themes [10]. We used the Dedoose software programme for the qualitative analysis [11].
Our research and reporting follow the criteria recommended in the Standards for Reporting Qualitative Research (SRQR) [12].

Ethical approval
We obtained ethical approval from the Institutional Review Board at the Harvard T. H. Chan School of Public Health. All participants provided verbal informed consent to participate.

RESULTS
Mirroring the chaos and conflicting demands of global COVID-19 pandemic on health system and the delivery of essential maternal newborn health care, the study participants observed facing both crises and opportunities. The themes which emerged from the data reflected how COVID-19 exercised conflicting influences on the prioritisation of maternal health, occasionally hindering, yet sometimes facilitating or accelerating developments toward achieving the commitments outlined in the National Dialogues. Here, these emerging issues illustrate the tensions and the complex interplay between confronting the COVID-19 crisis and improving maternal health system performance.

Theme 1.1: Need for continued political commitment
Respondents highlighted that the pressures on the health system exerted by the COVID-19 pandemic generally amplified and reinforced all the priorities identified during the National Dialogues; however, participants emphasised the need for sustained political will in the face of mounting pressures and shifting priorities to drive continued commitment and ensure that progress did not stall during the pandemic.

Theme 1.2: Emphasising maternal health as a human right
The extreme health risks and demand for care brought on by the COVID-19 pandemic reinforced the priority identified in some National Dialogues of framing maternal health as a human right for effective advocacy both at the political level and within hospitals and communities. At the political level, both government and non-state actors engaged in advocacy to ensure that the focus on human rights was not lost during the pandemic: The UN human rights organization contacted us saying that they were alarmed by the increase in maternal mortality due to COVID and then they proposed that we put together a series of seminars to put the issue on the table…Safe motherhood is a human right and implies many more rights, the right to health [and] to have the most advanced care available. -Key informant, Mexico At facility level, there was an emphasis on the health system's responsibility to treat women in need of maternity care, regardless of their COVID-19 status, as a basic human right.

If [a pregnant woman] was positive for COVID, then it was the responsibility of the hospital to take care of that female. So, these were the changes which were brought into place… -Key informant, Pakistan
At community level, respondents emphasised the need to provide people with information about basic rights related to maternal health during COVID as a strategy to empower communities.
Our projects…are advocating for these safe routes of care for women free from COVID infection and for giving communities dignified, concrete and easy-to-understand information.

Theme 1.3: COVID-19 exacerbated known fragilities and challenges in the health system
The COVID-19 pandemic exacerbated health system fragilities previously identified as priorities for improving maternal health and survival. Informants in some settings spoke of broad, overall weaknesses in their systems, such as deficiencies in the organisation of services, while others spoke of the ongoing need to address specific fragilities that were made more pressing during COVID, such as emergency care, distribution of health workers, and availability of midwives. Informants from all countries also described how COVID-19 exacerbated access constraints that were highlighted in the National Dialogues before the pandemic. These constraints amplified fears of poor treatment that were made worse when combined with the COVID-19 crisis.

Theme 2.1: COVID-19 diverted attention from maternal health
Even while amplifying the needs in areas identified as priorities during the National Dialogues, the acute demands of the COVID-19 crisis made governments re-focus their priorities, leading to halts in programmes and advocacy efforts due to limited human resources, funding, and system capacity.
We worked, let's say, with the state health services, and we worked and made strategies and all that, and then when the health emergency came, the States told us to wait, that is, almost, right now, we don't even now talk because we have to deal with COVID.

Theme 3.1: Synergies between COVID-19 and urgent maternal health issues
Despite the challenges brought by the COVID-19 pandemic, respondents described some synergies that emerged between the urgency of the COVID-19 crisis and the ability to bring attention to urgent needs in the realm of maternal health care that were identified at the National Dialogues. Thus, COVID-19 created a platform that activists could use to reinvigorate advocacy for continued investment in maternal health.

Theme 3.2: COVID-19 response created new programmatic opportunities
Given the impact the pandemic has had on maintaining essential routine care and health services, informants commented that COVID-19 had in some cases created programmatic opportunities to sustain and improve aspects of MCH service delivery and integrate it with the COVID-19 response.
We The need to understand the pandemic's rapidly changing epidemiology of and measure its effects and evolution in real time also created a platform for improved data collection for maternal health.

Theme 4.1: Pressure of responding to COVID-19 jeopardised quality of care
From a quality-of-care standpoint, COVID-19 exacerbated existing health workforce challenges and brought health workers to the breaking point, leading to lack of attention to commitments related to improving quality of care. Participants were concerned about a lack of both training and supervision because of the demands brought on by the pandemic.
We engaged health workers themselves. And most of them said the challenge was that they were not trained, not given training on…precautionary measures…for tending to patients. And that was a major reason why they were not actually going out to attend to patients.

Theme 4.2: COVID-19 drained financial resources from maternal health
One way that COVID-19 markedly hindered advancement toward the maternal health commitments across settings was that it drained significant financial resources away from efforts in maternal health.
Last year, 2020, most of the funds have been drawn away, or the commitments were not fulfilled, because of the lack of funds, because they were withdrawn, and they were drawn away towards COVID.

But from the family planning perspective, all I can tell you is that Pakistan has really run dry on contraceptives in the last one year. Hardly any province… or the central warehouse…procured or was able to procure contraceptives… because of the financial issues, and also because of the some of the regulatory issues. -Key informant, Pakistan
The donor landscape has also increased or changed, and so funding priorities and the fiscal landscape is constricting…seriously constricting. -Key informant, Nigeria

Theme 5.1: Government commitment was critical
In some cases, informants described successful achievement of objectives that were set, highlighted, or reinforced during the National Dialogues. Respondents reported notable progress in some areas, even more remarkable given the COVID-19 context. In those cases, a theme that emerged was that continued government commitment was critical to achieving planned activities during the pandemic.

Theme 5.2: Progress was slow, but continued
Some respondents emphasised that, despite the pandemic delaying the realisation of the objectives and commitments of the National Dialogues, they managed to raise awareness through advocacy efforts and achieve activities planned during the Dialogues.

Theme 4.3: Transferring locus of control to local level
In the face of widescale challenges national governments faced due to the pandemic, a theme emerged describing a transfer of the locus of activities to local levels. Participants described being able to make progress at the local level on commitments, even when progress at the national level was stalled. Participants also discussed forging deeper connections with communities to fill coverage gaps, while strengthening the connection between communities and the health system.
Working with traditional midwives, and thus being able to make that click, so to speak, between the community, the traditional midwives, and the health services. -Key informant, Mexico Different activities to address maternal health were prioritised due to COVID-19

DISCUSSION
The onset of the COVID-19 pandemic overturned plans and upended health care systems worldwide, as communities, facilities, health systems, and governments focused on survival. Two to four years after multi-stakeholder National Dialogues were carried out in partnership with government ministries and development partners in seven low-and middle-income countries, the produced plans and intended outcomes were heavily affected. In some cases, new opportunities were presented, while elsewhere, progress towards the agenda outlined in the National Dialogue was halted.
A pattern of paired dualities emerged. For example, for already fragile systems across low-and middle-income countries, the pandemic amplified and worsened health system deficiencies. While this highlighted and brought increased urgency to the maternal health advocacy priorities outlined in the National Dialogues, it also meant those priorities were often superseded by the emergency response to the COVID-19 crisis by health systems staggering under its burden, on top of routine care needs. Similarly, while COVID-19 was seen (in certain ways and in certain contexts) as a catalyser that cleared the path for broad health system improvements upon which maternal health priorities could ride, respondents more often reported that the maternal health agenda items prioritised during dialogues before the pandemic had been greatly delayed or lost in the rush to respond to COVID-related health system emergencies. It has been widely recognised that COVID-19 exposed and exacerbated health disparities globally, while markedly jeopardising maternal health among the most marginalised and disadvantaged populations [13][14][15]. Our findings underscore the critical risks associated with health inequities and health system deficiencies and the need to address them in order to make maternal health care service delivery more robust to external pressures, such as global pandemics. logistical support. We are also thankful to our organisational partners for the National Dialogues: White Ribbon Alliance (WRA) and Management Sciences for Health (MSH). We are grateful to Kim Whipkey (WRA) and Martha Murdock (MSH) for their help identifying stakeholders. Ethics statement: Ethical approval was obtained from the Institutional Review Board at the Harvard TH Chan School of Public Health. All participants provided verbal informed consent to participate. Finally, respondents across the countries recounted health system setbacks and associated health-related tragedies -increased maternal mortality, increased mistreatment of women seeking care, widening health inequities, worsening quality of care, and degradation of community trust in health systems. However, they also noted adaptations such as shifting the locus of advocacy and activity from national to sub-national focal areas, catalytic changes in response to the crisis (including the development and improvement of digital communication and data technology), and increased awareness of the importance of identified priorities (including a human rights approach to maternal health). Other studies have noted similar important context-specific adaptations that resulted from COVID-19-related health systems challenges to ensure the continuity of maternal health service delivery, for example, related to supporting community-based efforts and front-line health workers [16] or strategically increasing home-based care (or out of hospital care) delivery led by midwives on home-based care provided by midwives [17]. Calls to ensure that maternal health services uphold women's and children's rights despite the urgent pandemic response reverberated globally [18]. As the pandemic begins to subside, country programmes may consider whether and how to institutionalise and optimise the adaptations made during the pandemic to better meet maternal health needs.
Our study has several strengths and limitations. It included a broad range of perspectives from a diverse group of participants in five low-and middle-income countries. Despite this diversity, we were unable to achieve even participation across all countries due to the ongoing COVID-19 pandemic at the time of data collection. Further, our cross-comparative perspective means that we cannot also provide a deep analysis of local context. Many participants in the National Dialogues were at the forefront of COVID-19 response efforts in their countries and were unable to participate in our data collection activities. We believe that engaging a facilitator who was involved in the National Dialogues to conduct the FGDs and KIIs was largely a strength of our study, in that there was already a strong rapport and shared experience built between the participants and the facilitator. In fact, we believe that it may have reduced recall bias, as the facilitator was able to draw on both personal and publicly available documentary artifacts to revisit the proceedings of the National Dialogues during the FGDs and KIIs. Given that the topic of discussion was not particularly sensitive, nor were the participants beholden in any way to the facilitator, we do not believe that this arrangement resulted in any social desirability bias that may have impacted our findings. In particular, the discussion centred largely on contextual observations, rather than personal actions, thus we do not believe that participants would have felt any pressure to respond a particular way when reflecting on progress made or challenges faced. Further, we adapted the outcome harvesting methodology for our study and did not implement it in its complete form. For example, we were not able to map developments against the actors responsible for incremental change or include external substantiators. While these adaptations represent limitations in terms of fidelity to the model, we also believe that they represent a more practical and feasible approach that may be useful for future evaluations to draw on this methodology, given the intensity of inputs required to carry out the methodology in its full form.

CONCLUSIONS
Our data suggest that the priorities for maternal health system performance improvement to drive toward ending preventable maternal deaths, and the advocacy commitments designed to increase the salience of upstream policy and health system-level determinants of maternal health and survival that were outlined by multiple stakeholders in LMIC prior to the global COVID-19 pandemic largely remain true. If anything, they have been amplified and reinforced by the unprecedented pressure that health systems in these contexts have confronted.